Taking and Storing Notes and Recordings
Keeping records that are appropriate, accurate, relevant, lawful and secure is part of the commitment that counsellors and psychotherapists make to ethical practice. The nature of the work we do means that the information we record about our clients and their lives is often deeply intimate. As such, we occupy a privileged position and need to take great care to ensure that we respect and honour the trust placed in us. The following should offer some guidance with this.
* Client records in paper and electronic forms should be stored securely at all times. This means that they must be adequately protected from unauthorised intrusion or disclosure. For example, at a minimum, written records should be placed in a locked filing cabinet; recording devices and computers should be password-protected and data encrypted; and computer security systems, such as anti-virus and firewall, should be kept up-to-date.
* Clients must be informed about how written notes and recordings are kept, when and how they are archived, and about the therapist’s duty to respect the privacy of those notes.
* In the context of working with couples, both partners have to give consent for access to records, even if only one partner wishes to view them. Therefore, records of any individual work should be stored separately.
* Client records can be legally accessed by other parties in certain circumstances. Therefore, it is important to inform clients of the specific circumstances that present a limit to confidentiality, and to gain clients’ consent to therapy on this understanding. Informed consent would normally be achieved by means of a consent form (which the client reads and signs) explaining the extent of confidentiality, your cancellation policy, your use of supervision and manner of recording notes.
* Practitioners need to keep in mind that other parties (including the client) may read the notes they make. Clients have an automatic right to see their records, and ethics committees, courts, lawyers, offenders who are involved in legal processes, and coroners, may have legal access to client records.
* Complete records should be kept for seven years after the last contact with the client, after which they should be disposed of in a manner that maintains confidentiality. The confidentiality of client records must be maintained beyond a client’s death, unless legal or ethical considerations demand otherwise.
* Intake information, including a clients name, date of birth, address, next of kin and GP details, should be kept totally separate from ongoing session notes.
* Ongoing session notes should be recorded as soon as possible after the session has been completed to ensure the record is accurate. Practitioners should only record what is relevant to the client’s goals and the therapy contract, and should include any concerns and actions taken where the client is assessed to be at risk or a risk to others. Each entry should be signed and dated by the therapist.
* Any contact with clients outside of the counselling session should also be recorded. This includes emails, messages left with reception or on voice mail, phone calls, and transcripts of SMS messages.
* Any action the therapist takes concerning the client, such as suggesting referral to another agency or support group, or contacting the client’s GP or psychiatrist, should also be recorded, as well as the outcome.
* Missed sessions should also be recorded, including any follow-up by the therapist.
* At the end of the therapy relationship, a short summary of the therapy process should be written up, and this should include the initial goals of the therapy and whether the presenting problem was resolved.
* A professional executor should be appointed (see the Professional Executor section below) who will be able to inform clients and manage their records in the event of the therapist’s death, sudden illness or serious accident.